Provider Demographics
NPI:1043689672
Name:WILT, JEREMY LEE (NP)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:LEE
Last Name:WILT
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9431 COUNTY ROAD 403
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47111-8946
Mailing Address - Country:US
Mailing Address - Phone:812-256-6391
Mailing Address - Fax:
Practice Address - Street 1:9431 COUNTY ROAD 403
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:IN
Practice Address - Zip Code:47111-8946
Practice Address - Country:US
Practice Address - Phone:812-256-6391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-24
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005761A363L00000X
IN28165750A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
INF0915751OtherAANP CERTIFICATION
IN28165750AOtherINDIANA LICENSE NUMBER